Evergreen Retirement Home
Profile & contact details
|Premises name||Evergreen Retirement Home|
|Address||120 Rathgar Road Henderson Auckland 0610|
|Service types||Rest home care|
|Certification/licence name||Henderson Retirement Home Limited - Evergreen Retirement Home|
|Current auditor||HealthShare Limited|
|End date of current certificate/licence||06 December 2017|
|Certification period||12 months|
|Provider name||Henderson Retirement Home Limited|
|Street address||121B The Drive Epsom Auckland 1023|
|Post address||121B The Drive Epsom Auckland 1023|
Progress on issues from the last audit
What’s on this page?
This rest home has been audited against the Health and Disability Services Standards. During the last audit, the auditors identified some areas for improvement.
Issues from their last audit are listed in the corrective actions table below, along with the action required to fix the issue, its risk level, and whether or not the issue has been reported as fixed.
A guide to the table is available below.
Details of corrective actions
Date of last audit: 11 May 2017
|Outcome required||Found at audit||Action required||Risk rating||Action status||Date action reported complete|
|A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers.||Staff have not had training around key aspects of care and support such as abuse and neglect, the Code, aspects of clinical care. Neither of the staff have completed interRAI training. Staff do not have an annual performance appraisal.||Ensure that staff have access to training relevant to their roles. Provide staff with access to training around interRAI. Ensure that all staff have an annual performance appraisal.||PA Moderate||Reporting Complete||16/01/2017|
|The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed.||There is no evidence of review of the business plan or that the business plan reflects current direction and goals. A transition plan is not yet documented.||Ensure that the business plan reflects the goals of the service and that this is reviewed at regular intervals. A transition plan is not yet documented. (Required prior to purchase).||PA Moderate||Reporting Complete||28/11/2016|
|Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals.||Chemicals are not locked away.||Ensure that chemicals are kept in a safe and secure place when not in use by staff.||PA Moderate||Reporting Complete||07/12/2016|
|An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken.||Complaints raised through family meetings are not documented on the complaints register and there is no evidence that these have been resolved.||Document all complaints on the complaints register with evidence of implementation of the complaints policy and resolution of issues.||PA Moderate||Reporting Complete||16/01/2017|
|The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required.||Not all incident forms record evidence that family have been informed.||Ensure that family are informed when an incident has occurred.||PA Low||Reporting Complete||16/01/2017|
|The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk.||Observations of vital signs are inconsistently documented for an unwitnessed fall or when there maybe potential injuries.||Ensure that the process for review of the resident following an unwitnessed fall or if there is a potential change in status of the resident is implemented.||PA Low||Reporting Complete||16/01/2017|
|The appointment of appropriate service providers to safely meet the needs of consumers.||Staff records are incomplete with four of five files not including evidence of referee checks or criminal vetting. The file for the registered nurse/manager was not able to be sighted.||Ensure that staff recruitment information is kept on file and that all staff have a complete file.||PA Moderate||Reporting Complete||16/01/2017|
|New service providers receive an orientation/induction programme that covers the essential components of the service provided.||Three of five staff files do not evidence completion of orientation.||Ensure that an orientation is provided to each new staff member.||PA Low||Reporting Complete||16/01/2017|
|All records pertaining to individual consumer service delivery are integrated.||Not all pages in the resident file include the name and identifying details of the resident.||Ensure that each page in the resident file includes the residents’ name and details.||PA Low||Reporting Complete||16/01/2017|
|A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines.||There is transcribing of as required medications on the administration sheet. At times, the use of prescribed lotions is not documented when administered.||Cease transcribing of instructions for administration of medication. Document when lotions are administered.||PA Low||Reporting Complete||16/01/2017|
|Service providers responsible for medicine management are competent to perform the function for each stage they manage.||Not all staff have completed an annual medication competency.||Ensure that all staff who administer medications complete an annual medication competency.||PA Low||Reporting Complete||16/01/2017|
|Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines.||Two staff so not always sign for the administration of controlled drugs.||Ensure that there are two staff who sign for the controlled drug administration.||PA Low||Reporting Complete||16/01/2017|
|Consumers who have additional or modified nutritional requirements or special diets have these needs met.||The dietician has not reviewed the menu since 2013. The main cook does not follow the menu and at times the diary indicates that the menu is repeated over two days.||Review the menu in a timely manner. Ensure that the cook follows the menu.||PA Moderate||Reporting Complete||16/01/2017|
|The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate.||Residents and family state that they are not engaged in the assessment or care planning process.||Engage residents and/or family in the assessment and care planning process.||PA Low||Reporting Complete||16/01/2017|
|The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning.||InterRAI assessments have not been completed six monthly. InterRAI assessments completed are current but generic and often state ‘refer to the care plan’. The general practitioner has not assessed the resident within 48 hours after admission for three of the residents reviewed (noting that this includes one resident admitted in 2016)||Provide evidence that assessments are completed six monthly. Ensure that interRAI assessments are completed by staff who are familiar with the current status of each resident. Ensure that the general practitioner assesses the resident within 48 hours of admission.||PA Moderate||Reporting Complete||16/01/2017|
|Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures.||There is no documentation to confirm that fire equipment is checked annually. Not all staff have a current first aid certificate and the rosters do not indicate that there is always someone on duty with a first aid certificate.||Document evidence that fire equipment has been checked annually Ensure that there is always a staff member on duty with a current first aid certificate.||PA Moderate||Reporting Complete||16/01/2017|
|Advance directives that are made available to service providers are acted on where valid.||Two advance directives have been signed by family members.||Ensure that advance directives are documented as per the policy.||PA Low||Reporting Complete||11/04/2017|
|The organisation has a quality and risk management system which is understood and implemented by service providers.||A quality plan has not been ratified and implemented to date.||Document, implement and review a quality plan.||PA Moderate||Reporting Complete||11/04/2017|
|Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers.||The internal audit schedule has not been fully implemented and the schedule is not dated. Quality data does not include the identification of trends or areas for improvement. Resident meetings have not been held since September 2015 and satisfaction surveys have not been circulated.||Implement the internal audit schedule for the current year. Use quality data to analyse trends. Ensure that there are mechanisms implemented that allow discussion of issues and quality data where appropriate with residents and family.||PA Moderate||Reporting Complete||11/04/2017|
|A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented.||Corrective action plans are not always documented and there is little evidence of documentation of resolution of issues.||Fully implement the corrective action planning process with resolution of issues documented.||PA Moderate||Reporting Complete||11/04/2017|
|Entry criteria, assessment, and entry screening processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies.||One needs assessment for a resident potentially requiring a different level of care had not been received by the service. Not all admission agreements are signed on the day of entry or prior to entry to the service.||Access the outstanding needs assessment asnsoon as possible and ensure that any needs assessment reports are sent to the service in a timely manner. Ensure that admission agreements are signed on the day of entry to the service.||PA Moderate||Reporting Complete||11/04/2017|
|The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness.||The laundry does not have an adequately defined clean/dirty area.||Ensure that the laundry has a clean and dirty area defined.||PA Moderate||Reporting Complete||11/04/2017|
|The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety.||There is environmental restraint, by the way of an outside garden gate having a key pad lock.||Document the use of environmental restraint as per policy.||PA Low||Reporting Complete||11/04/2017|
The outcome required by the Health and Disability Services Standards.
Found at audit
The issue that was found when the rest home was audited.
The action necessary to fix the issue, as decided by the auditor.
Whether the required outcome was partially attained (PA) or unattained (UA), and what the risk level of the issue is.
The outcome is partially attained when:
- there is evidence that the rest home has the appropriate process in place, but not the required documentation
- when the rest home has the required documentation, but is unable to show that the process is being implemented.
The outcome is unattained when the rest home cannot show that they have the needed processes, systems or structures in place.
The risk level is determined by two things: how likely the issue is to happen and how serious the consequences of it happening would be.
The risk levels are:
- negligible – this issue requires no additional action or planning.
- low – this issue requires a negotiated plan in order to fix the issue within a specified and agreed time frame, such as one year.
- moderate – this issue requires a negotiated plan in order to fix the issue within a specific and agreed time frame, such as six months.
- high – this issue requires a negotiated plan in order to fix the issue within one month or as agreed between the service and auditor.
- critical – This issue requires immediate corrective action in order to fix the identified issue including documentation and sign off by the auditor within 24 hours to ensure consumer safety.
The risk level may be downgraded once the rest home reports the issue is fixed.
Whether the necessary action is still in progress or if it is complete, as reported by the rest home to the relevant district health board.
Date action reported complete
The date that the district health board was told the issue was fixed.
Before you begin
Before you download the audit reports, please read our guide to rest home certification and audits which gives an overview of the auditing process and explains what the audit reports mean.
What’s on this page?
Audit reports for this rest home’s latest audits can be downloaded below.
Full audit reports are provided for audits processed and approved after 29 August 2013. Note that the format for the full audit reports was streamlined from 16 December 2014. Full audit reports between 29 August 2013 and 16 December 2014 are therefore in a different format.
Prior to 29 August 2013, only audit summaries are available.
Both the recent full audit reports and previous audit summaries include:
- an overview of the rest home’s performance, and
- coloured indicators showing how well the rest home performed against the different aspects of the Health and Disability Services Standards.
Note: From November 2013, as rest homes are audited, any issues from their latest audit (the corrective actions required by the auditor) will appear on the rest home’s page. As the rest home completes the required actions, the status on the web site will update.
Audit reportsAudit date: 11 May 2017
Audit type:Surveillance Audit
- Evergreen Retirement Home - May 2017 (docx, 34.59 KB)
- Evergreen Retirement Home - May 2017 (pdf, 136.05 KB)
Audit type:Provisional Audit